Radiological Case: Mega appendix

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CASE SUMMARY

A 51-year-old man with no significant medical history presented to
the emergency department with moderate diffuse and constant abdominal
pain for the past 4 days. He was afebrile and his vital signs were
normal. His abdomen was mildly tender diffusely with more focal pain in
the right lower and upper quadrants without peritoneal signs. While in
the ED, the patient was given intravenous fluids and IV toradol for pain
management. Complete blood count, comprehensive metabolic panel, and
urinalysis were obtained and were noncontributory.

IMAGING FINDINGS

A 64-slice CT of the abdomen and pelvis with IV and PO contrast was
performed with multi-planar reconstructions (Figures 1-3). The exam
revealed a markedly enlarged, blind-ending, retrocecal tubular loop of
bowel that entirely filled with oral contrast, extending to the
subhepatic region, consistent with the appendix. It measured 2.5 cm wide
and 13 cm in craniocaudal dimension. Although its wall was slightly
prominent, there were no surrounding inflammatory changes and there was
no appendicolith. The patient’s symptoms improved after IV fluids and
Toradol were administered. After discussion with the on-call surgeon,
the patient was referred for outpatient follow-up and discharged. The
patient was contacted as an outpatient and indicated his symptoms
resolved completely without recurrence.

DIAGNOSIS

Mega appendix

DISCUSSION

The vermiform appendix is a continuation of the cecum of the large
intestine. The appendix ranges in length from 5-10 cm and 0.5-1 cm in
width.1 The annual rate of acute appendicitis was 9.38 per 10,000 in 2008.2 CT imaging has been reported to be 91-98% sensitive and 75-93% specific for the diagnosis of appendicitis.3
CT is commonly the first line approach to abdominal pain, with reported
accuracy rates up to 95-100% for the diagnosis of appendicitis.4 Prior to appendectomy, preoperative CT use was 94.7% in 2007, an increase from 18.5% in 1998.5 As a result, it is imperative for the radiologist to understand atypical anatomical variations of the appendix.

The appendix position can vary in relation to the other abdominal organs.6 The base is usually located about 2 cm below the ileocecal valve (Figure 1).1
However, the free end of the appendix can occupy a variety of
positions in relation to the small and large bowel: anterior, medial,
lateral, inferior, superior, superiorlateral and retrocolic.6 The average length of an appendix in an adult is 9.5 cm.7
Tamburrini et al evaluated the CT images of 372 patients. The appendix
was visualized in 305/372 of the abdominopelvic scans. The average
appendix diameter range was between 3-10 mmand wall thickness was 1.5 mm.6 Our patient had an appendix that was much wider and longer than the average appendix.

Large appendixes have been reported in the medical literature, mostly
outside of radiology. One of the first was reported in 1890 by F.
Grauer. He discovered a 33-cm-long appendix in a cadaver.8The next largest appendixes were discovered incidentally from autopsy specimens, 21.5, 22, 23 and 24 cm in length.8,9
In 1920, Lake reported the case of a 22-year-old male patient with
chronic abdominal pain who presented with acute appendicitis with a
perforated tip. He underwent an appendectomy, which revealed a 29.4 cm
appendix.10 In 1932, Collins performed a study evaluating
4,680 appendix specimens and discovered the longest appendixes found on
autopsies of men who died from conditions unrelated to the appendix; one
was a 28-cm appendix found in a 40-year-old man and the other was a
24.5 cm appendix found in a 76-year-old male.9 From 1923 to
1963, Collins performed a large study of 71,000 appendix specimens, 91%
of which were from appendectomy and 9% from post-mortem evaluation. The
Collins study was one of the largest studies to evaluate appendixes but
in the final report there was no assessment of the variability in size
of the appendix.11

In 2005, a case report of a 36-year- old man with a 28 cm, torsed and necrotic appendix was reported.12
A case report from the United Kingdom in 2009 described a 10-year-old
patient with a 17-cm-long inflamed appendix found during appendectomy.
The tip of the appendix had reached the subhepatic area.7 In
2011, a 25-year-old man was found to have a 20-cm, noninflamed appendix
adhering to his inguinal sac. He underwent a mesh plug hernia repair
with an appendectomy.13 The most recent reported case was in
2013 in India, where a 28 cm appendix was found during routine
dissection in a medical school cadaver laboratory.14

The previous case reports focus on cases of large appendixes found on
surgery or at autopsy. The vast majority lack diagnostic imaging
results. The classic CT findings of nonperforated acute appendicitis
include appendiceal wall thickening and dilatation, periappendiceal
inflammatory changes, wall hyperemia, and nonfilling with enteric
contrast.15 The appendix presented in our case report filled
entirely with oral contrast and lacked surrounding inflammatory changes,
thereby excluding the diagnosis of acute appendicitis despite its
unusually large dimension. That the patient’s pain resolved after
conservative management is also in keeping with the lack of acute
appendicitis. Furthermore, previous radiological literature has
described the importance of recognizing atypical anatomical variants on
CT scans of the appendix in order to appropriately diagnose
appendicitis. Various pitfalls have been discussed, including variable
appendiceal location, congenital abnormalities (such as malrotation),
and the interference of coexisting pathologies.16 However,
variability in size of the appendix and its role in accurate diagnosis
of appendicitis has not been explored to the same degree. Therefore, our
case depicts the importance of recognizing that a markedly enlarged
appendix may be a normal anatomic variant.

CONCLUSION

The myriad appearances of the appendix can make diagnosis of acute
appendicitis challenging. Our case is unique compared to other prior
case reports as our patient is a living, healthy, middle-age patient
with an extraordinarily large, non-inflamed appendix. Therefore, this
unusually wide mega appendix is felt to be a normal anatomic variant.
Familiarity with such an atypical appearance can allow for a more
accurate diagnostic approach, help prevent the erroneous diagnosis of
acute appendicitis, and help avoid unnecessary procedures.

About the Author

Prepared by Dr. Belani, Ms. Ahmed, and Dr. Bramwit while at the
Department of Radiology, Rutgers-Robert Wood Johnson University
Hospital, New Brunswick, NJ, and Dr. Stoev while at the Department of
Emergency Medicine, St. Peter’s University Hospital, New Brunswick, NJ.